Review ArticleThe Impact of Pain Assessment on Critically Ill Patients’Outcomes: A Systematic Review
Evanthia Georgiou,1 Maria Hadjibalassi,2 Ekaterini Lambrinou,2
Panayiota Andreou,2 and Elizabeth D. E. Papathanassoglou2
1Education Sector, Nursing Services, Ministry of Health, 1 Prodromou & Chilonos Street 17, 1448 Nicosia, Cyprus2Cyprus University of Technology Department of Nursing, 15 Vragadinou Street, 3041 Limassol, Cyprus
Correspondence should be addressed to Evanthia Georgiou; [email protected]
In critically ill patients, pain is a major problem. Efficient pain management depends on a systematic, comprehensive assessment ofpain. We aimed to review and synthesize current evidence on the impact of a systematic approach to pain assessment on criticallyill patients’ outcomes. A systematic review of published studies (CINAHL, PUBMED, SCOPUS, EMBASE, and COCHRANEdatabases) with predetermined eligibility criteria was undertaken. Methodological quality was assessed by the EPHPP qualityassessment tool. A total of 10 eligible studies were identified. Due to big heterogeneity, quantitative synthesis was not feasible. Moststudies indicated the frequency, duration of pain assessment, and types of pain assessment tools.Methodological quality assessmentyielded “strong” ratings for 5/10 and “weak” ratings for 3/10 studies. Implementation of systematic approaches to pain assessmentappears to associate with more frequent documented reports of pain and more efficient decisions for pain management. There wasevidence of favorable effects on pain intensity, duration of mechanical ventilation, length of ICU stay, mortality, adverse events, andcomplications.This systematic review demonstrates a link between systematic pain assessment and outcome in critical illness. How-ever, the current level of evidence is insufficient to draw firm conclusions.More high quality randomized clinical studies are needed.
1. Introduction
Despite several decades of research, pain is still a significantproblem for critically ill patients throughout their stay in theintensive care unit (ICU). Inaccurate pain assessment andthe resulting inadequate treatment of pain in critically illadults can have significant physiological and psychologicalconsequences. Underdiagnosed pain has been linked to anumber of adverse outcomes including increased infec-tion rate, prolonged mechanical ventilation, hemodynamicderangements, delirium, and compromised immunity [1–3].Appropriate pain management depends on the systematicand comprehensive assessment of pain to guide decision-making regarding titration of analgesia and administration of“as needed” medications [4, 5]. However, the extent to whichsystematic pain assessment may in itself have an effect oncritically ill patients’ outcomes remains unclear. Despite theexistence of recommendations and guidelines on the subject
of pain assessment and management as well as the existenceof validated tools to measure pain in verbal and nonverbalpatients, their implementation and use in routine clinicalpractice appear to be scarce and inconsistent [6]. Moreover,althoughmost ICUs have protocols for pharmacological painmanagement in place, or even pro re nata (prn) medicalorders, the means to assess the presence and intensity of painin critically ill individuals have been inconsistent, thereforelimiting the benefit of analgesia protocols [7].
2. Aim
This study focuses on pain assessment as an independentintervention, and it aims to review current evidence onhealthrelated outcomes of the systematic use of pain assessmenttools in the ICU. Evaluation of the efficacy of different painmanagement protocols is beyond the scope of this review,
Hindawi Publishing CorporationBioMed Research InternationalVolume 2015, Article ID 503830, 18 pageshttp://dx.doi.org/10.1155/2015/503830
2 BioMed Research International
which targets to explore the impact of systematic monitoringof pain indicators in the ICU. The study was driven bythe following research question formulated according to thePICO methodology (Patient, Intervention, Comparison, andOutcome) [8].
“In critically Ill adults does implementation ofa systematic assessment of pain, compared tono systematic assessment, improve patients’ out-comes with regard to (a) level of pain and agita-tion, (b) appropriate use of analgesics and seda-tives, (c) length of ICU stay, (d) complicationsand adverse events, (e) duration of mechanicalventilation and days off ventilator, (f) patientsatisfaction, and (g) mortality?.”
3. Background
Although pain is reported as a predominant stressor that canactivate many pathophysiological mechanisms in criticallyill patients, assessment rates of pain in ICU remain low[18]. This is mainly due to critically ill patients’ inability tocommunicate their pain, due to either sedation, or cognitiveimpairment, paralysis, or mechanical ventilation. The mul-ticenter patient-based DOLOREA study described currentpractices in analgesia and sedation use for 1,381 mechanicallyventilated patients during their first week in the ICU. It wasfound that only 42% of patients received pain assessmentson day 2 (D2) in ICUs, although 90% of patients wereconcomitantly given opioids [19]. The positive associationbetween the ability to assess and document patients’ painand the sufficient management of pain has been previouslydocumented [20, 21]. Inaccurate pain assessment and theensuing inadequate treatment of pain in critically ill adultscan affect all bodily systems with a plethora of physiologicand psychological consequences [22, 23] involving short- andlong-term clinical outcomes of critically ill patients [24].
Inconsistent use of standardized tools has been recog-nized as a leading factor in inadequate pain control. Gelinasand coworkers [25] found that of 183 documented painepisodes in intubated patients, use of a pain scale wasmentioned in only 1.6% of cases. Although assessment of painbehaviors was common (73% of episodes), these assessmentswere observed and documentedwithout the use of a valid andreliable tool. In another investigation of 1,360 mechanicallyventilated critically ill patients, Payen and coworkers [19]found that pain was not assessed in 53% of patients whowere receiving analgesia, andwhen painwas assessed, specificpain tools were used only 28% of the time. In addition, ina recent multicentre prospective observational study morethan 50% of the included ICUs reported the availability ofpain assessment tools and protocols for the management ofpain; however their application was rare (pain scale 19.1% andprotocol 25.0%) [26].
In the “clinical practice guidelines for the managementof pain, agitation and delirium in the critically ill adult”published by the Society of Critical Care Medicine (SCCM)it is recommended that pain is routinely monitored in alladult ICU patients [27]. Patient self-report through use of
the numeric rating scale (NRS) ranging from 0 to 10 iswidely recognized as the best pain assessment tool. However,in case of noncommunicative patients, use of a valid andreliable behavioral pain tool, like the behavioral pain scale(BPS) and the critical-care pain observation tool (CPOT)[27], is suggested. It is widely accepted that the use ofreliable behavioral pain assessment tools can assist healthcare providers in the early identification of pain in criticallyill patients and subsequently in the prompt and efficientmanagement of pain [5, 28].
4. Materials and Methods
4.1. Search Strategy. A focused literature search was under-taken with consultation with a professional librarian, fromDecember 2013 to March 2014. CINAHL, PUBMED, SCO-PUS, EMBASE, and COHRANE databases were searchedusing the terms “pain assessment” OR “pain evaluation”AND “critical care unit” OR “intensive care unit” AND“pain assessment tools” OR “pain assessment scales” AND“mechanical ventilation” OR “length of stay” OR “level ofpain” OR “agitation” OR “hypnotics and sedatives” OR“analgesic drugs” OR “complications and adverse events”OR “mortality” OR “patient satisfaction.” References ofidentified studies were also checked for relevancy. Hand-searches of relevant journals and search of gray literature(Open Archives.gr, Proquest Dessertations and Thesis) werealso performed.
After searching all sources, 1,153 articles were accumu-lated and exported into referencemanager software, refworks(ProQuest forWord version 4.3).This permitted easy removalof duplicates (𝑛 = 103). Study titles were then screened (elec-tronically using the referencemanager) independently by tworeviewers who selected studies appropriate for inclusion inthe review (𝑛 = 217). During the next phase abstracts andfull text of the retrieved articles were read and compared bythe reviewers against to the inclusion and exclusion criteria.During this phase, 200 articles were excluded. Finally, 17articles were considered for inclusion in the review. Afterconsultation with a third reviewer and consensus, 7 morewere excluded with reasons either of not appropriate design(3 studies) or not relevant outcomemeasures (4 studies).Thiseffort resulted in 10 eligible articles (Figure 1). Subsequently,data were extracted, summarized, and analyzed. Prismaguidelines were employed to guide analysis and reporting ofresults.
4.2. Selection Criteria. The decision to include studies wasbased on predetermined criteria. Inclusion criteria com-prised: (a) a study population consisting of adult criticallyill patients within the ICU, irrespective of their ability tocommunicate and whether they were on mechanical venti-lation support or not, (b) implementation of one or morepain assessment tools as single intervention, and (c) reportingthe effect of pain assessment practice on patient outcomesincluding one ormore of the following: level of pain, durationof mechanical ventilation, days off ventilator, length of ICUstay, patient satisfaction, complications and adverse events,appropriate use of analgesics and sedatives, and mortality.
BioMed Research International 3
Records identified through database searching
Scre
enin
gIn
clude
dEl
igib
ility
Iden
tifica
tion
Additional records identified through other sources
Records after duplicates removed
Potentially eligible articles
Records excluded based on title screening-not
relevant
Abstract and full-text articles assessed for
eligibility
Records excluded at abstract and full text
screening- not relevant and not
suitable design
Eligible articles
Studies included in the review
Full-text articles excluded,
with reasons
(n = 1145) (n = 8)
(n = 1050)
(n = 217)(n = 833)
(n = 200)
(n = 17)
(n = 17)
(n = 10)
(n = 7)
Figure 1: Flowchart of the literature search and article selection process.
No time or language limitations were set. Studies employ-ing concurrent interventions including a formal protocolprescribing interventions for the management of pain, eitherpharmacological and/or nonpharmacological, were excluded,in order to avoid the confounding effect of additional inter-ventions. Studies investigating children or neonates wereexcluded.
4.3. Quality Assessment of Selected Studies. The QualityAssessment Tool for Quantitative Studies (QATQS), Effec-tive Public Health Practice Project Quality assessment tool(EPHPP-2008) [29], was employed to score identified studiesin order to enhance the consistency of results [30]. QATQSwas chosen because it includes questions related to nonran-domized and observational designs such as quasiexperimen-tal and before-and-after studies. It has been reported as a
valid tool for assessing the quality of a study and for makingcomparisons between studies, while addressingmajor threatsto validity [31–33]. QATQS employs five criteria which eval-uate the likelihood of selection bias, quality of study design,presence of confounding variables, validity and reliability ofthemethod of data collection, and the number of withdrawalsand dropouts [29]. The overall study quality is considered tobe strong if none of the quality domains is rated as weak,moderate if one domain is rated as weak, and weak if two ormore domains are rated as weak. The methodological qualityof the identified articles was independently assessed by tworeviewers. Each reviewer assessed and rated all the studiesindependently based on the above assessment tool. Reviewersthen went through each criterion and compared the scores ofeach study noting down any differences.The level of interrateragreement was assessed by the kappa coefficient. A thirdreviewer was appointed from the beginning of the study, in
4 BioMed Research International
order to resolve potential disagreements between assessorsusing the consensus method.
5. Results
5.1. Quality Assessment. An almost perfect interrater agree-ment was observed, with kappa coefficient for each of the sixcomponent ratings ranging from 0.79 to 0.87 (𝑃 < 0.0001)for all studies. Methodological quality assessment on thebasis of the EPHPP quality assessment tool yielded “strong”ratings for the 5/10 included studies, “moderate” ratings for2/10, and “weak” ratings for 3/10 (Table 2). Owing to thepreexperimental, pretest-posttest nature of designs, severalthreats to validity are potentially present, involving selectionbias and interactions with history, testing, instrumentation,and regression to the mean.
5.2. Characteristics of Participants. The identified studieswere published between 1995 and 2013 and they were con-ducted in different countries (Canada: 4 studies; Europe:2 studies; USA: 2 studies; Australia: 1 study). With regardto study design, 9/10 studies employed a preexperimentalpretest-posttest approach, and one study employed a two-group comparative approach (Table 1). No studies employingrandomized controlled trial designs (RCT) were identified.The number of participants included ranged from 30 [11]to 1144 [6]. All studies involved adult ICU patients fromeither surgical [10], mixed [6, 9, 12, 14, 15], cardiothoracic[16, 17], trauma [9, 11, 13], or neurosurgical ICUs [13]. Only6/10 studies reported the use of a scoring system for theassessment of incidence of organ dysfunction/failure and pre-diction of outcome of the critically ill patients, as a baselinemeasurement (Table 1). Two studies included patients whowere not intubated and were able to communicate [16, 17],and 5 studies included noncommunicative patients [6, 9, 11,12, 14], either on mechanical ventilation [11, 14] or not [13].Topolovec-Vranic et al. [13] assessed a mixed population ofcommunicative and not communicative patients and twostudies included consecutive ICU admissions on the basis ofpredetermined inclusion criteria [10, 15].
5.3. Characteristics of Studies and Limitations. The charac-teristics of the intervention and outcome measures varied; adetailed account is presented in Table 1. Interventions gen-erally included guidance on frequency and duration of painassessment and the method and choice of pain assessmenttools.
Rose et al. [9] used a before and after design to evaluatethe effectiveness of the introduction of C-POT in two ICUs,on the frequency of documentation of pain assessment andadministration of analgesics and sedatives in critically illpatients unable to self-report pain. Data were recorded fora maximum of 72 hours before and after implementationof the tool in both units. The authors recognized severalconfounding factors that might have influenced their results(i.e., staff turnover, differences in patients characteristics, etc.)and potential performance and ascertainment bias.
Radtke et al. [10] conducted a nonrandomized study withbefore (for two months) and after measurements (for twomonths) and one-year follow-up to compare the effectivenessof two training strategies (training according to the localstandard versus modified extended training) on the imple-mentation rate of the numeric rating scale (NRS), BPS forpain assessment, RichmondAgitation sedation Scale (RASS),and the delirium detection score (DDS). Possible sourcesof bias were reported, including unequal and heterogeneousgroups, selection bias and several confounding factors thatmay have had an impact on the results.
Arbour et al. [11] performed a pilot before-and-afterstudy to explore the impact of the implementation of theCPOT on pain management among mechanically ventilatedtrauma intensive care unit patients. Data were collected frommedical files 1 year before the implementation of the CPOTand 6 months after implementation. The exploratory natureof the study, along with the small heterogeneous sampleand sensitization to measurement, was acknowledged aslimitations by the authors.
Gelinas et al. [12] examined ICU nurses’ reports of painassessments, reassessments and of behaviors indicative ofthe presence of pain, as well as administration of anal-gesics/sedatives, and the effectiveness of pharmacologicalinterventions pre- and postimplementation of the CPOT. Abefore and after study design was used, incorporating threephases: a three-month preimplementation phase includingthe review of 30 medical files, a three-month implementationphase during which nurses were trained in the use of CPOT,and a postimplementation phase.The retrospective review ofmedical files, inconsistencies of implementation differencesin pretest/posttest tools and institutional changes during thestudy were acknowledged as limitations.
In the study by Topolovec-Vranic et al. [13] the Nonver-bal Pain Scale (NVPS) was implemented and effects wereexplored through a pre-postdesign. Preimplementation datawere gathered during a 4-week period. The NVPS documen-tation tool covered a 48-hour period. Nurses were instructedto assess and document patients’ pain scores every 4 hours,as well as before and after a procedure (e.g., suctioning,turning), and to consider pain management options if thepain score was greater than 4. The choice of NVPS, due toits limited content validity and reliability as a pain measurefor nonverbal patients [34], and also the potential selectionbias for the patient satisfaction survey were reported aslimitations.
Payen’s et al. [6] study was a part of a multicenterprospective cohort study of mechanically ventilated patientswho received analgesia on day 2 of their stay in the ICU.Propensity-adjusted score analysis was employed to comparethe duration of ventilator support and duration of ICU staybetween 513 patients who were assessed for pain and 631patients who were not assessed for pain. A variety of painassessment tools were used (BPS, VAS, verbal descriptorscale, NRS, and Harris scale). Limitations include nonad-justment for confounding factors and failure to account forinteractions between sedatives and opioids.
Williams et al. [14] used a before-and-after design toevaluate results of implementation of the Behavioral Pain
BioMed Research International 5
Table1:Summaryof
study
characteris
ticsandmainou
tcom
es(A
PACH
E:acuteph
ysiology
andchronichealth
evaluatio
n;BP
S:behavioral
pain
scale;CP
OT:
criticalp
ainob
servation
tool;H
CP:health
care
professio
nals;
ICU:intensiv
ecareu
nit;IQ
R:interquartile
range;LO
S:leng
thof
stay;M
V:mechanicalventilation;
NA:n
otassessed;N
RS:num
ericalratin
gscale;NS:
nonsignificant;pts:patie
nts;RA
SS:R
ichm
ondAgitatio
nsedatio
nScale;SO
FA:sequentialorgan
failu
reassessment).
Authors,
year
(cou
ntry)
Stud
ydesig
n/aim
Stud
ysetting
(ICU
type)
Samples
ize(𝑁)
Type
ofscale/instr
ument
used
and
specifics
ofnu
rses’
HCP
’straining
onuseo
fscales
Severityof
illness
measures
Outcome:levelof
pain/agitatio
nand
documentatio
nof
pain
assessments
Outcome:useo
fanalgesic
sand
sedativ
es
Outcome:ICU
leng
thof
stay
(LOS)
indays
(mean,
SD)
Outcome:adverse
events/
complications
Outcome:
hospita
lleng
thof
stayin
days
(mean,
SD)
Outcome:
duratio
nof
mechanical
ventilatio
nin
days
(mean,
SD)
Outcome:
days
offventilator
Outcome:
patie
ntsatisfaction
Outcome:
mortality
rate
Rose
etal.,
2013
[9]
(Canada)
Preexp
erim
ental
2-grou
ppretest-p
ostte
stdesig
n(preim
plem
entatio
nph
ase:5mon
ths,
postimplem
entatio
n:5mon
ths)
Aim
:tocompare
preimplem
entatio
nto
postimplem
entatio
npractic
eand
outcom
es
2clo
sedICUs
Mixed
ICU(m
edi-
cal/surgical/traum
a)+cardiovascular
ICU
𝑁=373(𝑛1=189
before
implem
entatio
n;𝑛2=184aft
erim
plem
entatio
n)
CPOT
Allnu
rses
received
specialtraining
(video
demon
strationand
instr
uctio
non
use
ofCP
OT)
Severityof
illness
measures:SO
FAmedian(IQ
R)6(3–8)for
mixed
ICUptsb
efore
implem
entatio
nand4(3–6
)after
implem
entatio
n8(5–11)for
cardiovascular
ICUptsb
efore
implem
entatio
n8
(6–11)for
Cardiovascular
ICUptsa
fter
implem
entatio
n
Prop
ortio
nof
pain
assessmentintervalswith
pain
assessment
documentedincreased
from
15%to
64%
(𝑃<0.001)
(cardiovascularu
nit);
from
22%to
80%
(𝑃<0.02)(mixed
ICU)
Mediantotaldoseo
fopioid
analgesics
decreasedfro
m5m
gto
4mg(𝑃=0.02)
(cardiovascularICU
)andincreasedfro
m27
mgto
75mgto
mixed
ICU
Mediantotaldoseo
fbenzodiazepines
decreasedfro
m12mgto
2mg
(𝑃<0.001)
(cardiovascularu
nit);
remainedun
changed
(mixed
ICU)
MedianLO
SICUin
Cardiovascular
ICUdecreased
from
2.0(IQR,
1.0–5.0)d
aysto
1.8(IQR,
1.0–3.0)d
ays
(𝑃=0.007);
inmixed
ICU
(median,
5.9;
IQR,
2.9–
13.6
days
before
andmedian,7.0
;IQ
R,5.0–
14.7
days
after)
NA
NA
Inthec
ar-
diovascular
ICUmedian
was
0.6
(IQR,
0.3–0.8)
days
before
CPOTand
0.5(IQR,
0.3–0.8)
days
after;
inthe
mixed
ICU
medianwas
3.9(IQR,
1.4–10.7)
days
before
implem
en-
tatio
nand
5.9(IQR,
3.0–
9.1)
days
after
NA
NA
NA
Radtke
etal.,
2012
[10]
(Germany)
Preexp
erim
ental
3-grou
ppretest-p
ostte
stdesig
n(preim
plem
entatio
nph
ase(retro
spectiv
edatacollection):2
mon
ths,
postimplem
entatio
n(prospectiv
e):2
mon
ths)with
1-year
follo
w-up
Aim
:tocompare
the
effectiv
enesso
ftwo
training
strategies
stand
ardtraining
for
pain
assessment
sedatio
nandagitatio
nversus
mod
ified
extend
edtraining
3surgicalICUs
𝑁=619
(𝑛1=241before
implem
entatio
n;𝑛2=228aft
erim
plem
entatio
n;𝑛3=150follo
w-up)
NRS
,BPS
,RASS
Standard
training
forn
ursesa
ndph
ysicians
inclu
dedlectures,
movie,hand-ou
tson
etoon
einstr
uctio
nEx
tend
edmod
ified
training
inclu
ding
establish
mento
flocalsup
portteam
Severityof
illness
measures:
APA
CHEII,SOFA
Frequencyof
mon
itorin
gperp
atient
andday
forp
ain(N
RS,B
PS)
ICU1:pretest2.3(1.4–3.2);
posttest4
.0(3.0–5.6);
𝑃<0.01
follo
w-up4.6(3.2–5.8);
𝑃<0.01
ICU2:pretest1.8(1.3–2.2);
post-
test:
2.2(1.8–2.6);
p2.6(1.5–3.5)
Follo
w-up:2.0(1.7–
3.0);
𝑃=0.02
ICU3:Pretest:(0.0–0
.0);
post-
test:
(0.0–0
.0);
𝑃=ns
Follo
w-up:2.6(1.5–3.5);
𝑃<0.01
N/A
Administratio
nof
analgesic
sdecreased
from
3.87
(SD=
2.59);to
2.47
(SD=
2.56)
ICU1:pretest
18(32);postte
st15
(20);
follo
w-up14
(21);𝑃=0.40
ICU2:pretest8
(7);po
sttest7
(7);follo
w-up
4(3);𝑃<0.01
ICU3:pretest9
(8);po
sttest7
(8);follo
w-up9
(11);𝑃=0.31
N/A
Num
bero
fcomplications
mean
decreasedfro
m4.53
(SD=5.19)to1.8
7(SD
=1.6
9)𝑃≤0.05
N/A
ICU1:
pretest355
(697);
posttest2
81(448);
follo
w-up
265(495)
𝑃=0.51
ICU2:
pretest7
(12);
posttest5
(8);
follo
w-up4
(9);
𝑃=0.06
ICU3:
pretest117
(196);
posttest8
3(154);
follo
w-up
149(244
)𝑃=0.74
N/A
N/A
OnICU2,
them
ea-
surement
ofNRS
/BPS
was
associate
with
redu
ced
mortality
(odd
sratio
(pain)
=0.365
[95%CI
:0.147–
0.866],
𝑃=0.022
6 BioMed Research International
Table1:Con
tinued.
Authors,
year
(cou
ntry)
Stud
ydesig
n/aim
Stud
ysetting
(ICU
type)
Samples
ize(𝑁)
Type
ofscale/instr
ument
used
and
specifics
ofnu
rses’
HCP
’straining
onuseo
fscales
Severityof
illness
measures
Outcome:levelof
pain/agitatio
nand
documentatio
nof
pain
assessments
Outcome:useo
fanalgesic
sand
sedativ
es
Outcome:ICU
leng
thof
stay
(LOS)
indays
(mean,
SD)
Outcome:adverse
events/
complications
Outcome:
hospita
lleng
thof
stayin
days
(mean,
SD)
Outcome:
duratio
nof
mechanical
ventilatio
nin
days
(mean,
SD)
Outcome:
days
offventilator
Outcome:
patie
ntsatisfaction
Outcome:
mortality
rate
Arbou
retal.
2011[11]
(Canada)
PILO
Tpreexp
erim
ental
2-grou
ppretest-
posttestd
esign
(preim
plem
ent
traumaICU
𝑛=30medicalfiles:
15before
implem
entatio
nand
15aft
erim
plem
entatio
nof
theC
POT
implem
entatio
nph
ase:1y
ear,
postimplem
entatio
n:6mon
ths)
Aim
:toexplorethe
impactof
the
implem
entatio
nof
theC
POTon
pain
managem
ent
andclinicaloutcomes
inmechanically
ventilatedtrauma
intensivec
areu
nit
patie
nts
TraumaICU
𝑛=30medicalFiles:
15before
implem
entatio
nand
15aft
erim
plem
entatio
nof
theC
POT
CPOT
Nursesw
eretaught
howto
usethe
CPOT
throug
hatraining
session
andpractic
edits
scoringmetho
dwith
patie
nts’
videotapes
Severityof
illness
measures:
APA
CHEII
Frequencyo
fpain
assessm
entsmean
increasedfro
m4.33
(SD=
2.32)to12.33
(SD=4.69)
𝑃≤0.001
Noof
pain
episo
desm
ean
increasedfro
m1.13(SD=
1.13);postimplem
entatio
n4.27
(SD=2.09)
𝑃≤0.001
Morph
ine
equianalgesic
dosage
meandecreasedfro
m15.60(SD=11.35);to
9.37(SD=8.94)
𝑃≤0.10
Administratio
nof
sedativ
esmean
decreasedfro
m1.3
3(SD=2.66
)to0.60
(SD=0.83)
Decreased
from
10.53
(SD=
11.16
)to5.33
(SD=5.86)
𝑃≤0.10
N/A
(Days)
mean
decreased
from
6.93
(SD=7.37)
to4.00
(SD
=5.0)
N/A
N/A
N/A
BioMed Research International 7
Table1:Con
tinued.
Authors,
year
(cou
ntry)
Stud
ydesig
n/aim
Stud
ysetting
(ICU
type)
Samples
ize(𝑁)
Type
ofscale/instr
ument
used
and
specifics
ofnu
rses’
HCP
’straining
onuseo
fscales
Severityof
illness
measures
Outcome:levelof
pain/agitatio
nand
documentatio
nof
pain
assessments
Outcome:useo
fanalgesic
sand
sedativ
es
Outcome:ICU
leng
thof
stay
(LOS)
indays
(mean,
SD)
Outcome:adverse
events/
complications
Outcome:
hospita
lleng
thof
stayin
days
(mean,
SD)
Outcome:
duratio
nof
mechanical
ventilatio
nin
days
(mean,
SD)
Outcome:
days
offventilator
Outcome:
patie
ntsatisfaction
Outcome:
mortality
rate
Gelinas
etal.
2011[12]
(Canada)
Preexp
erim
ental
2-grou
ppretest-
posttestd
esign
(preim
plem
entatio
nph
ase:×3mon
ths,
implem
entatio
nph
ase:×3mon
ths
post-
implem
entatio
n:×3mon
thsa
nd12
mon
ths)
Aim
:toevaluatethe
implem
entatio
nof
the
CPOTon
pain
assessmentand
managem
entn
ursin
gpractic
eswith
nonverbalcriticallyill
patie
nts
ICU
𝑁1=60ICUnu
rses
𝑁2=90medical
files
(30before
implem
entatio
n,30
3mon
thsa
fter
implem
entatio
n,30
12mon
thsa
fter
implem
entatio
n
CPOT
Allnu
rses
were
trainedin
theu
seof
CPOT
Severityof
illness
measures:NR
Reportso
fpainassessm
ents
increasedfro
m3,00
(median)
before
implem
entatio
nto
10.50at
3mon
thsa
nd12,00at12
mon
thsa
fter
implem
entatio
nDocum
entatio
nof
behaviorsind
icativeo
fthe
presence
ofpain
increased
from
0,00
(median)
before
implem
entatio
nto
1,00at
3mon
thsa
nd2,00
at12
mon
thsa
fter
implem
entatio
n.(𝑈=264.00,𝑃=0.005)
Reportso
fpain
reassessm
ents
postinterventionfre
quency
(%)increased
from
14(9.92%
)before
implem
entatio
nto
28(43.1%
),3mon
thsa
nd26
(59.1
%),12
mon
thsa
fter
implem
entatio
n
Numbero
fana
lgesic
bolusa
dministered
(median)
decreased
from
3,00
before
implem
entatio
nto
1,00at3mon
thsa
nd0,5at12
mon
thsa
fter
implem
entatio
n(𝐻=11.82,
𝑃<0.001)
Totalofequiana
lgesic
doses(median)
was
similarinthe
preimplem
entatio
ngrou
p(1,50)
andin
the3
mon
thsa
fter
implem
entatio
ngrou
p(2.25)
butw
assm
aller(0,25)at12
mon
thaft
erim
plem
entatio
nSedatives:
significant
decrease
inthe
numbero
fpropo
fol
bolus(𝐻=10.06,
𝑃<0.05)a
nddo
se(m
g)(𝐻=10.29,
𝑃<0.05)
administered
postimplem
entatio
n
N/A
N/A
N/A
N/A
N/A
N/A
N/A
8 BioMed Research International
Table1:Con
tinued.
Authors,
year
(cou
ntry)
Stud
ydesig
n/aim
Stud
ysetting
(ICU
type)
Samples
ize(𝑁)
Type
ofscale/instr
ument
used
and
specifics
ofnu
rses’
HCP
’straining
onuseo
fscales
Severityof
illness
measures
Outcome:levelof
pain/agitatio
nand
documentatio
nof
pain
assessments
Outcome:useo
fanalgesic
sand
sedativ
es
Outcome:ICU
leng
thof
stay
(LOS)
indays
(mean,
SD)
Outcome:adverse
events/
complications
Outcome:
hospita
lleng
thof
stayin
days
(mean,
SD)
Outcome:
duratio
nof
mechanical
ventilatio
nin
days
(mean,
SD)
Outcome:
days
offventilator
Outcome:
patie
ntsatisfaction
Outcome:
mortality
rate
Topo
lovec-
Vranicetal.
2010
[13]
(Canada)
Preexp
erim
ental
retro
spectiv
e2-group
pretest-p
ostte
stdesig
npreimplem
entatio
nph
ase:×4weeks,
postimplem
ent×
4weeks
Aim
:toevaluatethe
effecto
fthe
NVPS
implem
entatio
n
Traumaa
ndneurosurgicalICU
𝑛=40medical
chartsof
noncom
mun
icative
patie
nts(20
preimplem
entatio
nand20
after
implem
entatio
n)and
𝑛=26medical
chartsof
commun
icative
patie
nts(13
before
implem
entatio
nand
13aft
erim
plem
entatio
n)Fo
rthe
patie
nts
satisfactionsurvey
𝑛=64patie
nts(25
before
and39
after
theimplem
entatio
nof
NVPS
)
NVPS
patie
ntsatisfaction
survey
(mod
ified
oftheA
PS-POQ)
Nursesreceived
in-service
training
for2
weeks
(smallgroup
presentatio
ns,
Pocketeducation
cards)
Severityof
illness
measures:NR
Forn
oncommun
icative
patie
ntstotalnu
mbero
fdo
cumentedpain
assessmentsincreased
from
457to
584aft
erthe
implem
entatio
n;the
prop
ortio
nof
numerical
assessmentsincreased
from
131[29%]to297
[51%
];𝑃<0.001
andthen
umbero
fassessmentsperp
atient
perICU
dayincreased
from
2.2to
3.4;𝑃=0.02
Forc
ommun
icative
patie
ntstotalnu
mbero
fdo
cumentedpain
assessmentsincreased
from
90to
120;the
numericalassessments
increasedfro
m8(9%)to
61(51%
);𝑃<0.001
Atre
ndtowardan
increase
inthen
umbero
fassessmentsperp
atient
ICUdaywas
noted(before
6.0,aft
er10.3;
𝑃=0.07)
Patie
nts’ratin
gsof
their
“painrig
htno
w”o
nas
cale
from
0to
10didno
tdiffer
from
before
(4.3)toaft
er(3.9)implem
entatio
npatie
ntsreportsforthe
worstpain
youhaddu
ring
your
ICUsta
ywerelow
eraft
erim
plem
entatio
n(7.2)
than
before
implem
entatio
n(8.5);
𝑃=0.04
Thep
ropo
rtionof
patie
nts
repo
rted
theintensityof
theirp
aindu
ringtheir
ICUsta
yas
severe
was
redu
cedfro
m55%to
35%
Nodifferences
were
foun
din
thetypeo
fop
ioid
analgesic
sadministered
orthe
amou
ntof
medication
(morph
ine
equivalents)given
perp
atient
orper
patie
ntperICU
day
whencompared
from
before
toaft
erim
plem
entatio
n
Forn
oncom-
mun
icative
patie
nts,days
inICU(stand
ard
erroro
fthe
mean)
decreasedfro
m11.9(2.1)
to10.7(1.7);
𝑃=0.68aft
erim
plem
entatio
nFo
rCom
mu-
nicativ
epatie
ntsfrom
1.0(0.15
)to1.1
(0.14
);𝑃=0.72aft
erim
plem
entatio
n
N/A
N/A
N/A
N/A
Highlevels
ofsatisfaction
with
nosig
nificant
difference
between
theg
roup
s
N/A
BioMed Research International 9
Table1:Con
tinued.
Authors,
year
(cou
ntry)
Stud
ydesig
n/aim
Stud
ysetting
(ICU
type)
Samples
ize(𝑁)
Type
ofscale/instr
ument
used
and
specifics
ofnu
rses’
HCP
’straining
onuseo
fscales
Severityof
illness
measures
Outcome:levelof
pain/agitatio
nand
documentatio
nof
pain
assessments
Outcome:useo
fanalgesic
sand
sedativ
es
Outcome:ICU
leng
thof
stay
(LOS)
indays
(mean,
SD)
Outcome:adverse
events/
complications
Outcome:
hospita
lleng
thof
stayin
days
(mean,
SD)
Outcome:
duratio
nof
mechanical
ventilatio
nin
days
(mean,
SD)
Outcome:
days
offventilator
Outcome:
patie
ntsatisfaction
Outcome:
mortality
rate
Payenetal.
2009
[6]
(France)
Con
current2-group
comparativ
eBo
thgrou
psfollo
wed
upun
tildeathor
ICU
dischargeo
rfor
30days
intheICU
Aim
:toinvestigate
whether
anassociationexists
betweenpain
assessments,
MV
duratio
n,and
duratio
nof
ICUsta
yin
mechanically
ventilatedpatie
nts
receiving
analgesia
onday2of
theirICU
stay
43ICUsm
ultic
entre
𝑛=1144
Mechanically
ventilatedpatie
nts
who
received
analgesia
onday2;
𝑛=631ptsn
otassessed
forp
ain
versus𝑛=513
patie
ntsa
ssessedfor
pain
onday2
BPS,VA
S,Harris
Scale,NRS
,verbal
descrip
torscale
Severityof
illness
measures:SA
PSII
Patie
ntsa
ssessedforp
ain
wereM
orelikely
tobe
assessed
forsedation;
91%
versus
30%;𝑃<0.01
Theg
roup
ofpatients
who
werea
ssessed
forp
ain
(1)w
erem
orelikely
toreceivefentanyl𝑛
(%)184
(36)
versus
179(28);𝑃<0.01;
mored
oseo
fsufentanilmedian
(IQR),𝜇
g7.6
(4.2–10.9)
versus
5.1
(2.8–7.6);𝑃<0.01
and
Lessdo
seof
remifentanil,98
(64–
145)
versus
149
(77–214);𝑃=0.02
(2)m
orep
atients
weretreated
with
nono
pioids𝑃<0.01
andwerem
orelikely
toreceive
multim
odal
analgesia
;𝑃<0.01,
anddedicated
proceduralpain
assessmentand
treatment𝑃<0.01
Patie
ntsw
howere
assessed
forp
ain
received
fewer
hypn
otics,𝑛(%
);384
(75)
versus
544(86);
𝑃<0.01andlower
daily
doseso
fmidazolam
295(57)
versus
411(65);
𝑃<0.1
Neuromuscular
Blocking
agentswere
redu
cedin
patie
nts
with
pain
assessment
35(7)v
ersus8
3(13);
𝑃<0.01
Patie
ntsw
howerea
ssessed
forp
ainhad
shorter
duratio
nof
ICU
LOS(13versus
18days)
𝑃≤0.01
Ventilator-acquire
dpn
eumonia,𝑛
(%)for
thosen
otassessed
117(24)
versus
66(16)
𝑃<0.01
Thromboem
bolic
events,
n(%
)for
thosen
otassessed
13(3)v
ersus10
(2);𝑃=0.82
Gastro
duodenal
hemorrhagen
(%)for
thosen
otassessed
8(2)
versus
4(1);𝑃=0.39
Centralvenouscatheter
colonizatio
n,n(%
)for
thosen
otassessed
28(6)v
ersus19(5);
𝑃=0.45
N/A
Patie
nts
who
were
assessed
for
pain
had
shorter
duratio
nof
MV,
8versus
11days;
𝑃<0.01
Increased
odds
ofweaning
from
ventilator
odds
ratio
1.40;95%
confi
dence
interval
1.00–
1.98
N/A
Patie
nts
not
assessed
forp
ain;
𝑛=136
(22%
)versus
patie
nts
assessed
forp
ain;
𝑛=95
(19%)
Unad-
juste
dOdd
sRatio
(95%
CI);
0.91
(0.58–1.4
3)𝑃=0.69
10 BioMed Research International
Table1:Con
tinued.
Authors,
year
(cou
ntry)
Stud
ydesig
n/aim
Stud
ysetting
(ICU
type)
Samples
ize(𝑁)
Type
ofscale/instr
ument
used
and
specifics
ofnu
rses’
HCP
’straining
onuseo
fscales
Severityof
illness
measures
Outcome:levelof
pain/agitatio
nand
documentatio
nof
pain
assessments
Outcome:useo
fanalgesic
sand
sedativ
es
Outcome:ICU
leng
thof
stay
(LOS)
indays
(mean,
SD)
Outcome:adverse
events/
complications
Outcome:
hospita
lleng
thof
stayin
days
(mean,
SD)
Outcome:
duratio
nof
mechanical
ventilatio
nin
days
(mean,
SD)
Outcome:
days
offventilator
Outcome:
patie
ntsatisfaction
Outcome:
mortality
rate
Williamse
tal.2008[14
](Australia)
Preexp
erim
ental
2-grou
ppretest-
posttestd
esign
(preim
plem
entatio
nph
ase:6m
,po
stimplem
entatio
n:6m
)Aim
:Toevaluate
outcom
esbefore
and
after
intro
duction
ofscales
fora
nalgesia
andsedatio
n
Generalclo
sedICU
𝑁=769ventilated
patie
nts(369patie
nts
before
and40
0patie
ntsa
fter
implem
entatio
n)
BPS,RA
SSEd
ucationon
the
useo
fscales
was
provided
toallstaff
Severityof
illness
measures:
APA
CHEII
N/A
Forp
atientsw
hohad
completes
edation
data,the
prop
ortio
nof
patie
ntsreceiving
sedativ
eswith
orwith
outanalgesics
durin
gtheir
admissionwas
greaterinthea
fter
grou
p(88%
)thanin
theb
eforeg
roup
(57%
);𝑃<0.001
Itwas
similar
betweenthe
grou
ps:2.3days
before
implem
entatio
nversus
2.6days
after
implem
enta-
tion;
nosig
nificant
result
(𝑃=0.18)
Incidenceo
funp
lann
edextubatio
ndecreased
after
implem
entatio
n(2
unplannedextubatio
nsaft
erim
plem
entatio
nversus
7before
implem
entatio
n,𝑃=0.07)
N/A
Itdidno
tchange
significantly
after
the
scales
were
intro
duced
(median,
24versus
28ho
urs)
Forp
atients
who
received
mechanical
ventilatio
nfor9
6ho
urs
orlonger
(24%
),mechanical
ventilatio
nlaste
dlong
eraft
erim
plem
en-
tatio
nof
the
scales
(𝑃=0.03)
N/A
N/A
N/A
BioMed Research International 11
Table1:Con
tinued.
Authors,
year
(cou
ntry)
Stud
ydesig
n/aim
Stud
ysetting
(ICU
type)
Samples
ize(𝑁)
Type
ofscale/instr
ument
used
and
specifics
ofnu
rses’
HCP
’straining
onuseo
fscales
Severityof
illness
measures
Outcome:levelof
pain/agitatio
nand
documentatio
nof
pain
assessments
Outcome:useo
fanalgesic
sand
sedativ
es
Outcome:ICU
leng
thof
stay
(LOS)
indays
(mean,
SD)
Outcome:adverse
events/
complications
Outcome:
hospita
lleng
thof
stayin
days
(mean,
SD)
Outcome:
duratio
nof
mechanical
ventilatio
nin
days
(mean,
SD)
Outcome:
days
offventilator
Outcome:
patie
ntsatisfaction
Outcome:
mortality
rate
Chanqu
eset
al.2006[15]
(France)
Preexp
erim
ental
prospective2
-group
pretest-p
ostte
stdesig
n(preim
plem
entatio
nph
ase:21
weeks,
postimplem
entatio
n:29
weeks)
Aim
:tomeasure
the
impactof
implem
entatio
nof
the
syste
maticevaluatio
nof
pain
andagitatio
nby
nurses
Medical-surgical
ICU
𝑁=230ICUpts
controlgroup
,𝑛=100;intervention
grou
p,𝑛=130
BPS,NRS
,RASS
Aperio
dof
4wks
oftraining
for
physicians
and
resid
entswho
received
anoral
educationand
writtensupp
ort
basedvigorous
Assessmentand
treatmento
fpain
and/or
agitatio
nNursesw
ere
trained
individu
allyatthe
bedsidetoevaluate
pain
andagitatio
nlevels
Severityof
illness
measures:SA
PSII
Them
edianob
servation
rateof
syste
matic
evaluatio
nof
pain
and
agitatio
nwas
high
erin
the
interventio
ngrou
p;75.0
(62.0–
90.0)for
pain
and
77.1(70.0–
90.8)for
agitatio
nthan
thec
ontro
lgrou
p58.6(40.0–
76.7)for
pain
and64
.0(50.0–
81.7)
fora
gitatio
n;𝑃<0.001
Theincidence
ofpain
and
agitatio
nwas
significantly
lower
intheintervention
grou
pthan
thec
ontro
lgrou
p:63
versus
42%
(𝑃<0.002)for
pain
and
29versus
12%(𝑃<0.002)
fora
gitatio
nTh
eincidence
ofsevere
pain
andsevere
agitatio
nweres
ignificantly
lower
intheinterventiongrou
p:36
versus
16%(𝑃<0.001)for
pain
and18
versus
5%(𝑃<0.002)for
agitatio
nAmon
gpain
andagitatio
nevents,
ther
ateo
fsevere
pain
eventsevaluatedby
anNRS
level>
6andther
ate
ofsevere
agitatio
nevents
evaluatedby
aRASS
level
>2was
significantly
lower
intheinterventiongrou
p:57
of176versus
24of
168
events(𝑃<0.001)a
nd42
of82
versus
9of
31events(𝑃<0.03),
respectiv
ely
Amon
gthea
nalgesic
andsedativ
edrugs
used
durin
gthetwo
phases,tramadolwas
theo
nlydrug
used
significantly
more
frequ
ently
inthe
interventio
ngrou
p(16versus
27%,
𝑃=0.05)
Therew
asno
significantd
ifference
amon
gdrugsu
sed
forc
ontin
uous
sedatio
nin
thetwo
grou
ps:M
idazolam
,prop
ofol,ore
ither
was
used
for
continuo
ussedatio
n,respectiv
ely,in87%,
7%,and
6%in
control
grou
pversus
74%,
16%,and
10%in
the
interventio
ngrou
p(𝑃=0.18)
Fentanyl,m
orph
ine,
oreither
was
used
for
continuo
ussedatio
n,respectiv
ely,in89%,
2%,and
9%in
controlgroup
versus
80%,8%,
and12%in
the
interventio
ngrou
p(𝑃=0.31)
Nosig
nificant
differencein
medianlen
gth
ofsta
yin
ICU
betweenthe
twogrou
ps8.5
(4.0–14.7)
inthe
controlversus
7.0(4.0–13.0)
intheintervention
grou
p;𝑃<0.38
Markeddecrease
inno
socomial
infections
ratein
the
interventio
ngrou
p;11/13
0(8)v
ersusc
ontro
lgrou
p17/10
0(17);
𝑃<0.05
N/A
Marked
decrease
inthetotal
duratio
nof
ventilatio
n,hrs;120
(48–312)
inthe
interventio
ngrou
pversus
65(24–
192)
inthec
ontro
lgrou
p;𝑃=0.01
N/A
N/A
No
significant
difference
inmortality
inICU
between
thetwo
grou
ps12
(12)
inthe
control
versus
19(15)
inthe
interven-
tiongrou
p;𝑃<0.76
12 BioMed Research International
Table1:Con
tinued.
Authors,
year
(cou
ntry)
Stud
ydesig
n/aim
Stud
ysetting
(ICU
type)
Samples
ize(𝑁)
Type
ofscale/instr
ument
used
and
specifics
ofnu
rses’
HCP
’straining
onuseo
fscales
Severityof
illness
measures
Outcome:levelof
pain/agitatio
nand
documentatio
nof
pain
assessments
Outcome:useo
fanalgesic
sand
sedativ
es
Outcome:ICU
leng
thof
stay
(LOS)
indays
(mean,
SD)
Outcome:adverse
events/
complications
Outcome:
hospita
lleng
thof
stayin
days
(mean,
SD)
Outcome:
duratio
nof
mechanical
ventilatio
nin
days
(mean,
SD)
Outcome:
days
offventilator
Outcome:
patie
ntsatisfaction
Outcome:
mortality
rate
Voigtetal.
1995
[16]
(USA
)
Preexp
erim
ental
2-grou
ppretest-
posttestd
esign
Pre-
and
postimplem
entatio
nph
ased
urationno
trepo
rted
Aim
:toexam
inethe
impactof
nurses’use
ofas
tand
ardizedpain
flowsheetto
documentp
ain
assessmentsand
pharmacologic
managem
ento
npatie
nt-reportedpain
intensity
SurgicalHeartUnit
𝑁=61(𝑛=30
preimplem
entatio
ngrou
pand𝑛=31
postimplem
entatio
ngrou
p)
Standardized
pain
flowsheet
NRS
Severityof
illness
measures:NR
The
distr
ibution
ofpain
intensity
scores
ininter-
ventiongrou
pwas
shifted
tolower
values
relativ
eto
thosein
controlg
roup
for
Averagepain
(𝑈=1150,
𝑃=0.001),
now
pain
(𝑈=1094,𝑃=0.015)
and
least
pain
(𝑈=1069,𝑃=0.02)
Docum
entatio
nof
pain
was
greatly
improved
ininterventio
ngrou
pforthe
operativeday(𝑈=756,
𝑃=0.004)forday
1(𝑈=1343,
𝑃<0.01)a
ndford
ay2
(𝑈=627,𝑃<0.01)
Theintervention
grou
preceived
more
pain
medications,
morph
ine
equivalents-on
day1
than
thec
ontro
lgrou
p(𝑡=−2.44,
𝑃=0.02)
Nosta
tistic
aldifferencew
asfoun
don
theo
perativ
eday
(𝑡=0.37,𝑃=0.72)
day2(𝑡=0.96,
𝑃=0.34)o
rfor
the
totalamou
ntgiven
whilein
theICU
(𝑡=1.92, 𝑃=0.06)
Nosig
nificant
difference
betweenthe
grou
ps(𝑈=861,
𝑃=0.27)
N/A
N/A
No
significant
difference
betweenthe
grou
ps(𝑈=975,
𝑃=0.43)
N/A
N/A
N/A
Meehanet
al.1995[17]
(USA
)
Preexp
erim
ental
2-grou
ppretest-
posttestd
esign
(retrospectiv
ephase
×2mon
ths
prospectivep
hase
from
1992
to1993)
Aim
:toexam
ine
nursingpractic
eregardinganalgesic
administratio
nand
measure
pain
intensity
andpatie
ntsatisfactionwith
pain
managem
ent
practic
es
CardiothoracicICU
𝑁=101
(retrospectiv
echarts
review𝑛=50and
concurrent
prospectives
ample
of51
patie
nts)
VAS,pain
relief
satisfaction
questio
nnaire
Severityof
illness
measures:NR
Them
eanVA
Sscorew
ason
lyavailablefor
the
prospectiveg
roup
(3.8–4
.59)
Amou
ntof
time
analgesia
was
held
before
extubatio
nwas
decreasedin
prospectiveg
roup
(5.41h
rsin
retro
spectiv
egroup
versus
4.25
hrsin
prospective)
Agreatern
umbero
fpatie
ntsinthe
prospectiveg
roup
received
procedural
analgesia
(64%
)Th
eprospectiv
egrou
preceived
significantly
more
analgesia
throug
hday3than
retro
spectiv
egroup
(𝑃<0.01)w
hereas
retro
spectiv
egroup
received
more
analgesia
laterin
theirICU
stay
(𝑃=0.016)
Inthep
rospectiv
egrou
pmorep
atients
received
hypn
otics
(statistic
snot
available)
76%of
the
prospective
grou
ptransfe
rred
onday2or
soon
erfro
mtheICU
versus
54%in
the
retro
spectiv
egrou
p
N/A
N/A
No
differencein
timeo
fextubatio
nbetweenthe
twogrou
ps:
(retrospec-
tiveg
roup
meanof
16.11
hrs
versus
14.1hrsin
the
prospective
grou
p)
N/A
96%of
the
prospec-
tiveg
roup
experi-
enced
effectiv
epain
man-
agem
ent
Nodata
were
available
forthe
ret-
rospectiv
egrou
p
N/A
BioMed Research International 13
Table 2: Quality Assessment of included studies, EPHPP.
Scale and theRichmondAgitation-Sedation Scale for patientsreceiving mechanical ventilation. Data were collected for 6months before and 6 months after training and introductionof the scales. Selection bias and failure to control for con-founding factors were acknowledged as limitations.
Chanques and coworkers [15] used a pre-postinterventiondesign and implemented use of BPS (for noncommunicativepatients) in combination with NRS (for communicativepatients) to evaluate pain. The preimplementation data col-lection was 21 weeks during which BPS, NRS, and RASSwere measured twice daily, at rest, by independent observers.This was followed by a period of 4 weeks of training and asubsequent 29-week intervention phase, during which nursesassessed pain and agitation levels and notified physiciansif BPS > 5 or NRS > 3 RASS > 1. Several limitations areacknowledged including unequal rates of measurements atthe pre- and postimplementation phases and the fact thatthe incidence and intensity of pain and agitation events wereobserved only at rest.
Voigt et al. [16] through a pre-postintervention designexamined the impact of nurses’ use of a standardized painflow sheet to document pain and pharmacologic manage-ment on the basis of NRS ratings as reported by patients.Additionally, within 24 hrs after transfer to the step-downunit, patients were interviewed regarding pain intensityexperienced in the surgical heart unit and at the timeof questioning. Lack of randomization and uncontrolledconfounding factors was reported as limitations.
Meehan et al. [17] reviewed retrospectively and prospec-tively the charts of adult cardiac-surgical patients to examinenursing practice regarding analgesia and to compare patients’outcomes. The subjects completed the visual analogue scale(VAS) twice daily, as a measure of pain intensity and the PainRelief Satisfaction Questionnaire on the day after transferfrom the cardiothoracic ITU. Failure to account for a numberof confounders and low generalizability to other ICU popu-lations was acknowledged.
5.4. Main Outcomes
5.4.1. Compliance and Documentation of Pain Assessments.Eight studies reported the impact of the pain assessmentprotocol on the documentation and compliance with sys-tematic pain assessment practice. Documented reports ofpain assessments and reassessments as well as reports ofthe presence of pain appeared to be more frequent afterthe implementation of pain assessment tools [9–13, 15, 16].Further, in the study by Payen et al. [6], patients with regularpain assessments were more likely to be assessed for sedationand for procedural pain as well. Only two studies did notreport on this outcome [14, 17].
Only in two studies, one involving trauma and neurosur-gical [13] and the other mostly medical patients, measures offeasibility of measurements were assessed. Topolovec-Vranicet al. [13] noted that 78% of nurses reported that NVPS waseasy to use and 80% were satisfied by its use, and Gelinas etal. [12] reported high interrated agreement after only a shorttraining.
5.4.2. Impact of Pain Assessment on Medications Used. Painassessment appeared to influence the administration ofmedi-cations in eight studies [6, 9, 11, 12, 14–17], with themajority ofstudies reporting better pain management and more efficientuse of analgesics and/or sedatives. Only one study reportedno difference in the type of opioid analgesics administeredor the amount of medication (morphine equivalents) afterimplementation of the pain assessment tool [13].
In the study by Rose et al. [9], implementation of thepain assessment tool had different effects on opioid andbenzodiazepine administration in the twoparticipating ICUs.Specifically, in the cardiovascular ICU, a small but significantdecrease in use of opioid analgesics and a large decrease inthe administration of benzodiazepines occurred, while in themixed ICU use of opioid analgesics increased dramatically,and benzodiazepine usage was unchanged. Similarly, in thestudy by Arbour et al. [11] analgesics were administered less
14 BioMed Research International
often and morphine equianalgesic dosages were lower inthe postimplementation compared to the preimplementationgroup. In the same study, while no statistically significant dif-ference was found, patients of the preimplementation groupreceived sedative agents twice as often. In another study,fewer analgesic and sedative agents were administered duringthe postimplementation phase [12]. In contrast, Williamset al. [14] reported more prolonged use of sedatives afterimplementation of the pain assessment protocol.
Chanques and coworkers [15] report significant changesinvolving both increase and decrease in doses of analgesicand psychoactive drugs, but no significant differences incontinuous infusion of sedatives in the intervention group.Only the dose of morphine administered as continuoussedation showed a trend to be higher in the interventiongroup.
In the study by Meehan et al. [17], the preimplementa-tion group received significantly more analgesia (morphineequivalents) through day 3, with the greatest difference beingon day 1, while the postimplementation group received moreanalgesia later in their stay. Similarly, Voigt et al. [16] ina sample of cardiac surgery patients reported more painmedication received on day 1 at the postimplementationgroup. Payen et al. [6] reported that more patients with painassessments were treatedwith nonopioids, compared to thosewithout pain assessments and that they also received fewerhypnotics and lower daily doses of midazolam. Finally, twostudies reported that patientswhowere assessed for their painwere more likely to have dedicated pain treatment duringprocedural pain events [6, 17].
5.4.3. Impact of Pain Assessment on Level of Pain. Threestudies examined the effect of systematic pain assessment oneither intensity or incidence of pain experienced by criticallyill patients, and they reported overall favorable outcomes.
Chanques and coworkers [15] reported that the incidenceof pain, as well as the rate of severe pain events (NRS >6), decreased significantly during the intervention phase.However, BPS pain scores and the rate of severe pain eventsbased on the BPS (BPS > 7) were not significantly differentcompared to the preimplementation phase. Similarly, in thestudy by Voigt et al. [16] the distribution of pain intensityscores in the postintervention group shifted towards lowervalues, relative to the distribution of those in the preinter-vention group. This difference was statistically significant forthe average and least amount of pain experienced during ICUstay and the pain experienced at the moment of questioning[16]. No pre-postimplementation comparisons were made inthe study by Williams et al. [14]. Topolovec-Vranic et al. [13]reported decreased retrospective patient pain ratings after theimplementation of theNVPS and a trend toward a decrease inthe time required to receive painmedication. Patients’ ratingsof their “pain right now” on a scale from 0 to 10 did not differfrom before to after implementation of the NVPS [13].
5.4.4. Impact of Pain Assessment on Duration of MechanicalVentilation. Eight studies examined the effect of system-atic pain assessment on duration of mechanical ventilation,
of which 2 studies reported significant decreases [6, 15].Payen et al. [6] report increased odds for weaning fromthe ventilator (OR: 1.40) and decreases risk of ventilator-associated pneumonia (VAP) (OR: 0.75) in the group ofpatients routinely assessed for pain. Likewise, Chanques et al.[15] report significantly decreased risk of VAP. In the studyby Arbour et al. [11], although no statistical difference wasfound in the duration of mechanical ventilation between the2 groups, there was a clear trend for decreased duration ofmechanical ventilation by approximately 3 days and almosthalf of patients in the preimplementation group (𝑛 = 7)were ventilated for a period of more than 96 hours asopposed to only 4 patients of the postimplementation group.However, interventions involving pain assessment practiceswere not associated with a significant reduction in durationof mechanical ventilation in 5 studies [9, 10, 14, 16, 17].
5.4.5. Impact of Pain Assessment on Occurrence of AdverseEvents and Complications. Four studies addressed the impactof pain assessment on the occurrence of adverse eventsand complications. Arbour et al. [11] reported that patientsin the postimplementation group showed a significantlylower number of complications, compared to the preim-plementation group, although they did not make specificmention to the type of complications. Similarly, Chanquesand coworkers [15] observed amarked decrease in the overallnosocomial infections rate in the intervention comparedto the control group, as well as significant decreases withregard to VAP, central catheter-related infections, urinarytract infections, and bacteremia. Likewise, Payen et al. [6]report significantly decreased rates of VAP, but no statisticalsignificant differences with regard to thromboembolic events,gastroduodenal hemorrhage, and central venous cathetercolonization. Nonetheless, in the study of Williams et al.[14] adverse events were equally distributed between the 2groups except for the incidence of unplanned extubationwhich was less, but not statistically significant so, in thepostimplementation group.
5.4.6. Impact of Pain Assessment on Patient Satisfaction.Only two studies assessed the impact of pain assessmenton patient satisfaction. In the study by Meehan et al. [17]almost all of the participants prospectively expressed theirsatisfaction with pain management in the cardiothoracicICU. Topolovec-Vranic et al. [13] stated that both before andafter implementation of systematic pain assessment, a largeproportion of patients reported that their physician or nurseexplained the importance of pain treatment to them, weresatisfied with the way their nurses and physicians respondedto their reports of pain and expressed their belief that thestaff in the ICU did everything they could to help controltheir pain.However, after implementation of theNVPS, fewerpatients reported a delay more than 5 minutes to receive painmedication when they requested it in the ICU.
5.4.7. Impact of Pain Assessment on ICU Length of Stay(LOS). Assessment of pain had no significant influence onICU length of stay in 4 studies [10, 14–16]. However, in
BioMed Research International 15
the study of Payen et al. [6] patients who were assessedfor pain had a shorter duration of ICU stay, by 5 days onaverage (adjusted OR: 1.43). A trend for decreased ICU LOSwas observed in two studies [9, 11]. Similarly, Meehan etal. [17] report a bigger percentage of patients (76%) in theprospective postimplementation group that were transferredon day 2 or sooner from the ICU compared with theretrospective preimplementation group (54%); this differencewas statistically significant.
5.4.8. Impact of Pain Assessment on Mortality. Only threestudies investigated the impact of pain assessment onmortal-ity. In one study [10], the implementation of pain monitoringand use of pain assessment tools were associated with adecrease in mortality (OR: 0.36), whereas in the othertwo studies there was no significant difference in mortalitybetween the two groups of patients (OR: 0.8–0.91) [6, 15].
6. Discussion
This review identified studies exploring the impact of sys-tematic pain assessment on critically ill patients’ outcomes.Due to heterogeneity in study design, patient populations,interventions, setting, and time of study, quantitative syn-thesis was not possible. Several methodological limitations,including preexperimental design approaches, limited con-trol of confounders and small sample sizes burden this bodyof evidence. However, data seem to indicate an associationbetween systematic pain assessment and improved patients’outcomes. Despite the perceived importance of pain for bothphysiological and psychological outcomes in critical illness[35], the lack of studies assessing the impact of pain mon-itoring is astounding. Correspondingly, it is worth-notingthat the results of this systematic review cannot be comparedwith other reviews as there are no systematic reviews ormeta-analyses focusing on the impact of systematic painassessment approaches on critically ill patients’ outcomes.Only one relevant narrative review was identified, whichexamined the importance of pain assessment and its potentialimpact, as part of reviewing different strategies for theimprovement of patients’ outcomes [18].
The findings of this review support the notion thatimplementation of validated pain assessment tools can have apositive impact on ICUnurses’ practice as evidenced bymorefrequent documented reports of pain assessments. Moreover,evidence showing alterations in use of analgesics and seda-tives may suggest that use of pain assessment tools can guideICUnurses inmakingmore efficient decisions regarding painand sedationmanagement. Despite heterogeneity in outcomevariables and measurements, as well as methodological lim-itations, this review suggests that implementation of system-atic pain assessment may also have a favorable impact onthe intensity of pain experienced by critically ill individuals.Most of the reviewed studies that evaluated the impact ofpain assessment on the level of pain seem to demonstratelower, albeit not always statistically significantly, pain ratingsafter the implementation of a pain assessment tool. However,despite reports of improved outcomes, the effect of systematic
pain assessment on duration of MV, adverse events, patientsatisfaction, hospital LOS, and mortality is obscured by thesmall number of studies addressing these outcomes, as wellas limitations in statistical power.
The lack of strong evidence to suggest an associationbetween systematic pain assessment and ICU length of stay,mortality, and duration of mechanical ventilation may bedue to the fact that, in most of the studies, pain assessmentfindings were not directly linked to prescribed pharmaco-logical interventions. Indeed, it is acknowledged that use ofsedation/analgesia protocols rather than choice of a specificsedation/analgesia scale is associated with outcomes [36]. It isnoteworthy that in one of the studies which demonstrated asignificant association with the duration of mechanical venti-lation physicians had received education regarding analgesicsand psychoactive drugs although no analgesia protocol wasimplemented [15].Therefore, systematic pain assessmentmaybe a valuable approach to rational and effective analgesia andsedation provided that clinicians possess adequate knowledgeregarding pain and sedation management.
Although unrelieved pain in the ICU has been linkedto adverse effects, such as prolonged mechanical ventilation,infections, hemodynamic instability, delirium, and depressedimmunity [1–3], such complications were rarely addressedin clinical ICU research. Only 3 studies reported on theseoutcomes with two studies demonstrating statistically signif-icant results in favor of the intervention group. Additionally,evidence with regard to incidence of other complications,such as gastrointestinal bleeding and thromboembolism, isso far inconclusive, probably partially owing to small samplesizes and small rates of such complications. Clearly moreresearch is needed to clarify the effect of systematic painassessments on ICU complications.
Finally, although patients’ satisfaction with their painmanagement is identified as an important criterion for assess-ing quality of care [37, 38], this was rarely addressed as anoutcome measure within the studies included in this review.Both studies which assessed the impact of pain assessment onpatient satisfaction demonstrated high levels of satisfactioneither pre- or postimplementation despite patients’ reports onthe existence of pain. This controversy has been extensivelydocumented in previous studies [39, 40] and it could beattributed to the fact that patients were still receiving care inthe hospital while interviewed and they were perhaps reluc-tant to express dissatisfaction with their care providers [13].
Although practicality of application of behavioral paintools is an obvious issue of interest, only two groups haveassessed feasibility ofmeasurements to find it high, after shortonly training. This is in line with a feasibility study regardingCPOT, in which the majority of participants (70%) reportedthat CPOTwas helpful and recommended its routine use [41].It is noteworthy that although behavioral pain tools were notdesigned specifically for neurosurgical patients, NVPS wasreported as easy to use and helpful in a trauma/neurosurgicalpopulation in one of the identified studies [13]. Recentadvances in application of behavioral pain scales addresstraumatic brain injury patients [42]. However, more researchmay be needed to establish the feasibility and validity ofbehavioral pain tools in this sensitive patient population.
16 BioMed Research International
Limitations. Limitations of this systematic review stem (a)from the literature search strategywhich excluded conferenceproceedings and (b) from limitations inherent in the identi-fied studies. Specifically, the lack of studies employing ran-domized controlled approaches highlights the limited level ofcurrent evidencewith regard to the impact of pain assessmenton critically ill patients’ outcomes. It is noteworthy thatthe majority of studies employed pretest-posttest designs,which yield less reliable forms of evidence than concurrent orrandomized designs.They are also subject to various types ofbiases especially in critical care, where facilities, staffing, andpatient case-mix are subject to substantial change over time.
In light of the aspect of variation in patient characteristicsand in pain assessment tools used between studies, findingsshould be comparable only in those cases where the same toolwas used and only among patients with the same character-istics. Variation in methods of pain assessment across studiesand the scarcity of reporting details on who was involvedin pain assessment may have confounded the findings ofthis review further. In some studies pain assessment wasconducted by the nursing staff and in other studies byindependent assessors with no detailed explanation of theirbackground. This may have accounted in part for the vari-ability of results. Another limitation stems fromdifferences inoutcomemeasures and intervention groups, which precludeduse of quantitative syntheses.
7. Conclusions and Implications
This systematic review on the impact of systematic painassessment on critically ill patients’ outcomes providedevidence emphasizing the link between systematic painassessment and short-term critically ill patients’ outcomes.Nevertheless, the current level of evidence is insufficient andmore high quality randomized clinical studies are essential. Insummary it is concluded that (a) implementation of validatedpain assessment tools can have a positive impact on theintensity of pain experienced by critically ill individuals,on more efficient use of analgesics and/or sedatives andon ICU clinical practice associated with more frequentassessment and documentation of pain, (b) more study isneeded to evaluate the effect of systematic pain assessment onprolonged mechanical ventilation, infections, hemodynamicinstability, delirium, depressed immunity, and survival, and(c) the link between systematic pain assessment in criticalcare and patient satisfaction need to be explored further.
In terms of nursing practice, pain assessment tools shouldbe incorporated into daily practice as it is recommendedin the most recent guidelines and quality improvementinitiatives [27].This will assist health care professionals in theprompt identification, early and efficientmanagement of painand also optimum use of sedatives and analgesics in the ICU.Further, clinical and theoretical training on pain assessmentshould be included in nursing and medical school curricula,as well as in continuous education in order to help cliniciansto better understand the importance of prompt identificationand management of pain.
This review highlights the need for further high qual-ity randomized clinical trials to establish the relationship
between systematic pain assessment and clinical outcomes indifferent ICU patients populations. Outcome measures haveto be expanded to include long term outcomes since currentresearch seems to demonstrate an association between acutepain management with a decreasing number of long termcomplications such as chronic pain [43] and posttraumaticstress disorder [44], as well as development of the post-ICU syndrome [45]. As such, it would be crucial to examinehow systematic pain assessment would affect those long termoutcomes.
Conflict of Interests
The authors declare that there is no conflict of interestsregarding the publication of this paper.
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